NURSING HOME WORKFORCE CHALLENGES: INCREASED NURSING STAFF LABOR COSTS AND USE OF AGENCY STAFF FROM 2017 TO 2021

Abstract Nursing homes face rapidly increasing wages and change their input mix as they face workforce shortfalls. For 15,959 freestanding NHs from 2017-2021, the proportion of hours worked by agency staff and the median wage cost per hour of agency and directly employed nursing staff were calculated from Medicare cost reports and Payroll-Based Journal data. The median hourly wage cost of directly employed staff (wage and fringe) increased 18.1% for RNs (to $41.99 in 2021), 19.8% for LPNs ($32.29), and 27.5% for CNAs ($19.62). The median hourly wage cost of agency staff (amount paid to staffing agency) increased at a faster rate and was substantially higher: 22.8% for RNs ($64.19); 28.3% for LPNs ($52.42), and 34.9% for CNAs ($33.73). The use of agency staff increased, starting from approximately 2% of all nursing staff hours for each of the nursing staff types in Q1 2017 to 5.6% hours for RNs, 9.4% hours for LPNs, and 8.8% hours for CNAs in Q4 2021. These observations have implications for quality and access to nursing home care. High use of agency staff may affect quality of nursing home care, and substantial wage differences between agency and directly-employed staff may affect worker satisfaction and attachment of directly employed workers. Hourly wage costs for all nursing staff have increased more rapidly than nursing home revenues, which only increased 16.6% over the study period; this suggests that, without payment rate increases, nursing homes may reduce labor inputs to contain costs, or may go out of business.

that also may affect outcomes, complicating the estimation of any causal relationship.Using the 2002-2018 Health and Retirement Study (HRS), we use family structure variables as instruments for both formal care and the combination of formal and informal care to estimate the causal impact of the home health care team on self-reported mental and physical health outcomes.Once the endogeneity of the care team is accounted for, having both formal and informal care leads to higher self-reported health and having only formal care leads to worse mental health outcomes, such as higher depression and lower positive affect, compared to informal care alone.Mobility measures seem unaffected by the type of home care provider.
Abstract citation ID: igad104.0121Balancing the safety of nursing home residents with their need for social interaction has emerged as a key challenge from the COVID-19 pandemic.Strict bans on nursing home visitation eventually led to growing concern that physical isolation may have unintended harms on nursing home residents.To address this concern, at staggered times between June 2020 and January 2021, 17 states implemented Essential Caregiver policies allowing nursing home visitation by designated family members or friends under controlled circumstances.Using the Nursing Home COVID-19 Public File and other relevant data, we analyze the effects of Essential Caregiver policies on COVID-19 and non-COVID-19 deaths for nursing home residents.To estimate plausibly causal effects, we employ recent innovations in difference-in-differences and event-study estimation.We find that on average, Essential Caregiver policies prevent 0.44 non-COVID-19 deaths, 0.42 COVID-19 deaths, and 0.86 total deaths per 1,000 residents in a two-week period, representing 8 percent, 17 percent, and 11 percent of the sample mean for the three outcomes, respectively.The effects are mainly driven by state policies that are mandatory or implemented without restrictions and are larger for high-quality facilities and highly staffed facilities.Our results suggest that nursing home residents derive substantial benefit from regular social interaction with family members and friends and from the additional care they provide.Our findings support the use and expansion of Essential Caregiver policies to balance resident safety and the need for social interaction for future infectious disease outbreaks.

EFFECTS OF ESSENTIAL CAREGIVER
United States,4. Harvard Medical School,Boston,Massachusetts,United States Nursing homes face rapidly increasing wages and change their input mix as they face workforce shortfalls.For 15,959 freestanding NHs from 2017-2021, the proportion of hours worked by agency staff and the median wage cost per hour of agency and directly employed nursing staff were calculated from Medicare cost reports and Payroll-Based Journal data.The median hourly wage cost of directly employed staff (wage and fringe) increased 18.1% for RNs (to $41.99 in 2021), 19.8% for LPNs ($32.29), and 27.5% for CNAs ($19.62).The median hourly wage cost of agency staff (amount paid to staffing agency) increased at a faster rate and was substantially higher: 22.8% for RNs ($64.19);28.3% for LPNs ($52.42), and 34.9% for CNAs ($33.73).The use of agency staff increased, starting from approximately 2% of all nursing staff hours for each of the nursing staff types in Q1 2017 to 5.6% hours for RNs, 9.4% hours for LPNs, and 8.8% hours for CNAs in Q4 2021.These observations have implications for quality and access to nursing home care.High use of agency staff may affect quality of nursing home care, and substantial wage differences between agency and directly-employed staff may affect worker satisfaction and attachment of directly employed workers.Hourly wage costs for all nursing staff have increased more rapidly than nursing home revenues, which only increased 16.6% over the study period; this suggests that, without payment rate increases, nursing homes may reduce labor inputs to contain costs, or may go out of business.

THE EFFECT OF GERMANY'S LONG-TERM CARE STRENGTHENING ACT II ON NURSING HOME USE
Freya Diederich, University of Bremen, Bremen, Bremen, Germany In Germany, out-of-pocket costs for nursing home care have substantially increased during the last years.There is an ongoing discussion whether these out-of-pocket costs should be capped.However, a decrease in costs may increase nursing home use and the social costs of nursing home care.This study analyzes how a change in out-ofpocket costs for nursing home care affects nursing home use.We use discontinuities in out-of-pocket costs that arose from Germany's Long-Term Care Strengthening Act II in 2017.The Long-Term Care Strengthening Act II decreased average nursing home care costs for people with higher care needs and increased average costs for people with lower care needs.Long-term care insurance data are analyzed using a regression discontinuity design.There is no significant change in nursing home use among people who enter long-term care with relatively high care needs.However, there is a significant decrease in nursing home use among those who enter long-term care with relatively low care needs.The results are robust regarding different specifications of the model.We conclude that the elasticity of nursing home use depends on the level of care needs.For people with high care needs, nursing home care is often without alternatives, whereas people with lower care needs may substitute nursing home care with informal care.A generous public policy does not necessarily increase demand for nursing home care.

THE HEALTH CARE COSTS OF DEMENTIA FOR MEXICANS AND MEXICAN AMERICANS IN MÉXICO AND THE UNITED STATES
Mónika López Anuarbe 1 , and Angela Gutierrez 2 , 1. Connecticut College, New London, Connecticut, United States, 2. Ohio University, Athens, Ohio, United States Dementia prevalence and costs affect subpopulations differently, generating healthcare and aging disparities.Most research on healthcare costs associated with dementia has overlooked cross-national comparisons among Hispanics in general and Mexicans in particular.This study utilizes the 2012-2018 Mexican Health and Aging Study (MHAS) and Health and Retirement Study (HRS) to assess: 1) relationships between geographic context and healthcare costs (hospitalization, medical, outpatient, prescription, dental); and 2) whether dementia status moderates the geographic context-healthcare costs relationship.We hypothesized that persons with dementia incurred higher healthcare costs in both countries, and that residents in less populated areas had lower healthcare costs than their counterparts.We used multivariable logistic regressions and generalized linear models, accounting for personal, healthcare access, and utilization factors.Results suggest that in 2012 (MHAS n = 15,723), persons with dementia in México had average healthcare costs that were 60.3% greater compared to those without dementia.Individuals with dementia also had a higher probability (11.9% p = 0.040) of incurring any healthcare costs in less densely populated areas (under 15,000 persons).In contrast, Hispanics participating in the HRS during that period (n=15,567), 58% of whom were of Mexican origin, did not have higher total healthcare costs if diagnosed with dementia, but incurred larger expenses in rural areas compared to their urban counterparts (p< 0.001).These results underscore how geographical context varies across countries and how dementia status can leave some individuals more financially vulnerable than others, affecting their access to healthcare services and overall health.

TECHNOLOGY AS A CATALYST FOR SUPPORTING AGING WITH DISABILITY Chair: Tracy Mitzner
Individuals aging with long-term disabilities may need support to perform and participate in everyday activities associated with well-being and quality of life.Technology solutions have potential to effectively promote autonomy and aging-in-place for this population.This symposium will highlight technology research and development efforts from the Rehabilitation Engineering Research Center on Technologies to Support Aging-in-Place for People with Long-Term Disabilities (RERC TechSAge).TechSAge is dedicated to understanding the needs of, and developing supportive technologies for people aging with long-term vision, hearing, and mobility disabilities.Mumma et al. will present insights from interviews of adults aging with vision loss due to glaucoma and macular degeneration regarding their